Membership Form

Please fill in the following information

Name: __________________________________________ Date of birth_______________

Address: __________________________________________________________________

City:__________________________________ State: _________ Zip: _______________

Telephone: ______________________ Email: ___________________________________

Beneficiary for MSA Insurance: _______________________ No. of Family Members_______

Club membership includes one life inusrance policy. Additional Dependant Life Insurance available for $2.00 per
person for $2000.00 of coverage. Please add family members, DOB & Beneficiary optional ($2.00/each) for
insurance below. If additional space is needed use back of form.

Name: ______________________________________ DOB: _________________

Name: ______________________________________ DOB: _________________

Name: ______________________________________ DOB: _________________

Name: ______________________________________ DOB: _________________

Name: ______________________________________ DOB: _________________

Name: ______________________________________ DOB: _________________